Cygnet Bury Hudson

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The service’s values were integrity, trust, empower, respect and care.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The values were embedded within documents and were the footer of the models of care.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff had the opportunity to share their views within team meetings and staff forums. The registered manager had also provided drop in sessions for staff to discuss confusion about sick pay within the service.

Staff could explain how they were working to deliver high quality care within the budgets available. Staff were very passionate about their roles and described how they advocated on behalf of patients to improve their experiences, for example improved facilities in the gym and recovery college, the opening of the social hub. The occupational therapy team had provided packs for patients with religious items for use during Ramadan.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. The registered manager had recently completed their PHD in the impact of co production in a forensic setting. Leaders were visible in the service and co chaired the patient forum.

The registered manager and clinical managers rotated the chairing of the staff forum to listen to staff members’ views and experiences.

Staff we spoke with told us how valued they felt within the service and that they knew who the leaders were and they were visible in the service and felt able to approach them.

Patients knew who the leaders were and told us they were visible in the service. Clinical managers based themselves on the wards to provide support, leadership and role modelling to the staff team. One of the clinical managers had developed prompts of how to respond to patients in distress, these included staying calm, using I statements, encouraging regulation, setting boundaries, reducing power struggles and reinforcing the positives. Leaders acknowledged with staff the intensity of working in the service and supported staff to rotate into roles within different wards to reduce staff burnout.

Leaders had a thorough understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. There were 2 clinical managers; one oversaw the wards for patients with a personality disorder and one oversaw the wards for patients with a mental illness. Leaders understood the challenges within the services and could explain what they were doing to address these. An example was the staff team were finding it difficult supporting a patient, the leaders approached commissioners and bespoke training was provided to the team about how best to support the patient. The skills gathered from the training would also be beneficial when supporting other patients.

Morning managers meetings were a supportive meeting to ensure there was oversight of the service and we saw leaders provide professional challenge and supported staff to explore potential reasons for patients changes in behaviour.

Leaders completed out of hours visits to review staffing, patient experiences, records evidenced support was provided to staff with developing their skills including record keeping and risk management.

Leadership development opportunities were available, including opportunities for staff. Management training was available for ward managers. Managers spoke positively about this opportunity and the skills and knowledge that had developed as a result.

Leaders enabled staff to attend reflective practice and Trauma Risk Management (TRiM) acknowledging the need for support for staff to continue providing high level of care to patients.

We create a positive culture where people feel that they can speak up and that their voice will be heard.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Annual patient surveys took place. Weekly ward based community meetings took place and monthly people’s council meetings.

Carer surveys took place quarterly. Quarterly carer events took place at the service and carers were encouraged to provide feedback as part of these. The main area for improvement was communication about their relatives care and progress in the service.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. This included feedback via the weekly community meetings on each ward, also feedback from patients in their review meetings and feedback via the people’s council, surveys and feedback boxes.

Patients were involved in decision-making about changes to the service. A food forum had enabled patients to review the menu and provide feedback to the chefs for areas of improvement. A new menu had been introduced as a result of the feedback and patients spoke positively about the changes. A gym forum had involved patients to give feedback about the design of the décor of the gym and the facilities in the gym, resulting in a welcoming environment with a variety of gym equipment and opportunities to participate in football and yoga too.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. The patient forum was co chaired by the registered manger or clinical manager and the people’s council was co chaired by the general manager, clinical manager and security manager on rotation. The staff forum was chaired by the registered manager or clinical manager, resulting in leaders hearing direct feedback about patient and staff’s experiences.

The service had a freedom to speak up guardian. There were freedom to speak up feedback forms for staff to use. The guardian had visited the service in December 2025 and collated a report with themes of feedback and actions for the service to take.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff had access to LGBT+ network, multicultural network and a multicultural mentorship programme.

Staff were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. Staff gave example of leaders being supportive and enabling staff to meet caring responsibilities they had.

Managers put reasonable adjustments in place for staff members to help them carry out their role. This included staff rotating around roles, adjustments for break times if they were fasting.

The provider undertakes equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

We do not always have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We do not always act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team or directorate level. There were standard agendas for all meetings to ensure consistency. This ensured and minutes confirmed that essential information, such as learning from incidents and complaints, was shared and discussed. Oversight of seclusion fed into the regional clinical governance meeting with the Regional Medical Director chairing both the regional clinical governance meeting and the long term segregation and seclusion review meeting.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. This included a change in policy and raising staff awareness about the use of Glyceryl trinitrate medicine.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Actions included increased BLS simulations and guidance relating to care records and support from clinical managers resulting in improved findings for BLS simulation and care record audits.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Commissioners regularly visited the service, external teams attended patient reviews and we saw social work representation at daily risk meetings.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register. This included increased acuity within certain wards in the service.

The service had plans for emergencies – for example, adverse weather or a flu outbreak.

The service mostly used systems to collect data from wards and directorates that were not over-burdensome for frontline staff. However, ward managers had to collate staffing figures, incidents and observations levels prior to the daily morning managers meetings.

Staff did not always have access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system did not always work well and did not always help to improve the quality of care. We saw and staff told us of the internet challenges which resulted in delays to meetings and external guests difficulties at joining the meeting remotely.

Information governance systems included confidentiality of patient records.

Ward managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Monthly governance reports were collated, members of the multidisciplinary team contributed to these, and these were discussed at the monthly regional operations governance meetings. A carer and expert by experience were involved in these meetings. A patient was involved in the local clinical governance meetings for the complaints and compliments agenda item. All patient identifiable information was anonymised as part of this process.

Information was in an accessible format, and was timely, accurate and identified areas for improvement. There was a power point presentation created with the information in a more accessible format with the use of graphs to visually show the information.

Although there had been significant improvements in governance since our last inspection, we identified breaches in relation to safe care and treatment and the environment in this inspection, however the service had the systems, processes and oversight to address these promptly and had started to address these following feedback during the inspection.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Directorate leaders engaged with external stakeholders – such as commissioners and Healthwatch. Regular contract review meetings took place with commissioners and case managers visited individual patients on the wards to review their care and progress.

Quarterly meetings took place with the GP surgery who provided weekly GP sessions at the hospital, the physical health nurses were included in this meeting. Agenda items included sharing lessons learnt, feedback from the GP’s and the service and actions were identified to improve the healthcare experience for patients.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. This was through people’s council, governance meetings and drop in opportunities.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff were given the time, support and opportunities for improvements and innovation and this led to changes. There were 3 quality improvement (QI) projects underway in the service at the time of our inspection.

The CPA standards project was a QI initiative designed to strengthen service user involvement, improve data quality, and ensure consistent delivery of the 20 CPA standards across all wards. The project introduced a structured, person centred checklist completed with patients prior to their CPA meeting, enabling them to express preferences, understand the process, and actively participate in planning their care. The checklists were in use at the service and next steps included training for staff and embedding the checklist in the CPA process.

Another QI project was the implementation of the Enabling Environments (EE) framework within the service to support the development of a psychologically informed, relationally safe, and recovery-focused therapeutic environment. The Enabling Environments programme, developed by the Royal College of Psychiatrists, is a nationally recognised framework designed to strengthen social relationships, improve therapeutic culture, and embed collaborative and enabling practices across healthcare environments. We saw the core values as agenda items in community meetings and staff had been provided with prompts of how to respond to patients in distress, these included staying calm, using I statements, encouraging regulation, setting boundaries, reducing power struggles and reinforcing the positives. West Hampton ward had participated in a self evaluation and had reflected on the value of belonging and identified examples where this was displayed in the ward were an Eid party and cultural awareness day.

Another QI focus was the implementation of the patient, carer, race equality framework (PCREF). A baseline audit using Cygnet’s PCREF audit tool was completed on 19 March 2026. Overall service compliance was 64%. The findings from the audit formed actions for the service. A group of volunteers including patients and staff agreed to oversee the implementation of the actions, with one meeting taken place at the time of the inspection. PCREF had been developed to raise awareness too.

A QI project being led by support workers and sponsored by the hospital manager was to strengthen annual leave planning, reduce end-of-year leave accumulation, improve workforce planning, protect staff wellbeing and minimise avoidable budget impact.

Staff had opportunities to participate in research. The registered manager had recently completed their PHD in the impact of co production in a forensic setting.

Medical advisory committee meetings took place with all doctors at the service, these included opportunities for peer support and training.

Innovations were taking place in the service. Staff and patients presented at a Royal College of Psychiatrists Enabling environments forum. The presentation focused on “Enhancing relational practices through enabling environment principles in a forensic setting” patients co facilitated the presentation.

The service had commissioned Relational Approaches: Working with Complexity training. This was created following discussion groups with staff, primarily focused on staff working on wards for patients with a personality disorder. Hospital staff were trained to facilitate the training and the training was then offered to the rest of the workforce.

Wards participated in accreditation schemes relevant to the service and learned from them. The service was reviewed by the Royal College of Psychiatrist’s Quality Network for Forensic Mental Health Services in March 2026. The medium secure services met 87% of the standards and the low secure services met 85% of the standards. Co production and least restrictive practice were noted as strengths within the service. Areas identified for improvement included those where QI projects were underway, the service had acted on the feedback.